This study addresses the Agency for Healthcare Research and Quality (AHRQ) research portfolio on patient safety. The aim of the patient safety portfolio is to identify risks and prevent patient injury associated with delivery of health care including examining effective ways to make systems changes and creating an environment within health care settings that prevents patient safety events. Pressure ulcers and falls are among the most common, preventable and costly patient safety events. Despite well-established evidence and widespread implementation of preventive care interventions national pressure ulcer rates (PUR) and fall rates (FR) remain high. Numerous studies have examined factors that improve or hinder quality of Care (QOC), including the QOC indicators PUR and FR. By and large it is understood that contextual factors are important to consider when examining PUR and FR, but there is little evidence on the longitudinal influence of contextual factors on PUR and FR. The prosed study includes contextual factors conceptualized as the nurse work environment (NWE) factors (staffing and professional nursing practice) and the environment within which the NWE resides conceptualized as the 3 levels of the health care system (community, hospital and nurse unit). The NWE factors affect nurse outcomes (satisfaction and turnover) and care interventions. Thus PUR and FR are affected by care interventions which in turn are affected by nurse outcomes and NWE factors which are impacted by community, hospital, and nursing unit characteristics. These relationships are understudied in rural hospitals. Comparisons of QOC indicators in rural and urban hospitals show mixed results suggesting other contextual factors besides location are important for QOC. Longitudinal studies, measuring context and identifying resources across the healthcare system, can elucidate these complex relationships. Building on 6 preliminary studies we propose a non-experimental longitudinal design, comparing rural and urban nursing units, using 2009-2013 (20 quarters) unit-level data from the National Database of Nursing Quality Indicators augmented with data on community and hospital characteristics from other data bases. We will first (specific aim 1) determine effects of care interventions for pressure ulcer and fall prevention on PUR and FR over 5 years. We will then add NWE factors and nurse outcomes (specific aim 2) and examine the effect NWE factors and nurse outcomes have on the relationships of care interventions and PUR and FR. Finally we will (specific aim 3) determine rural and urban differences in the effects of care interventions on PUR and FR and assess the extent to which the potential differences are attributed to NWE factors and nurse outcomes. For all 3 aims we will control for community, hospital, and nursing unit characteristics. Our study's results will inform administrative and policy strategies for examining and improving QOC in rural and urban nursing units.